International Institute for Population Sciences.
These authors contributed equally to this work.
Milbank Q. 2018 Mar;96(1):167-206. doi: 10.1111/1468-0009.12315.
Policy Points: Per-capita household health spending was higher in economically developed states and was associated with ability to pay, but catastrophic health spending (CHS) was equally high in both poorer and more developed states in India. Based on multilevel modeling, we found that the largest geographic variation in health spending and CHS was at the state and village levels, reflecting wide inequality in the accessibility to and cost of health care at these levels. Contextual factors at macro and micro political units are important to reduce health spending and CHS in India.
In India, health care is a local good, and households are the major source of financing it. Earlier studies have examined diverse determinants of health care spending, but no attempt has been made to understand the geographical variation in household and catastrophic health spending. We used multilevel modeling to assess the relative importance of villages, districts, and states to health spending in India.
We used data on the health expenditures of 101,576 households collected in the consumption expenditure schedule (68th round) carried out by the National Sample Survey in 2011-2012. We examined 4 dependent variables: per-capita health spending (PHS), per-capita institutional health spending (PIHS), per-capita noninstitutional health spending (PNHS), and catastrophic health spending (CHS). CHS was defined as household health spending exceeding 40% of its capacity to pay. We used multilevel linear regression and logistic models to decompose the variation in each outcome by state, region, district, village, and household levels.
The average PHS was 1,331 Indian rupees (INR), which varied by state-level economic development. About one-fourth of Indian households incurred CHS, which was equally high in both the economically developed and poorer states. After controlling for household level factors, 77.1% of the total variation in PHS was attributable to households, 10.1% to states, 9.5% to villages, 2.6% to districts, and 0.7% to regions. The pattern in variance partitioning was similar for PNHS. The largest interstate variation was found for CHS (15.9%), while the opposite was true for PIHS (3.2%).
We observed substantial variations in household health spending at the state and village levels compared with India's districts and regions. The large variation in CHS attributable to states indicates interstate inequality in the accessibility to and cost of health care. Our findings suggest that contextual factors at the macro and micro political units are important to reduce India's household health spending and CHS.
政策要点：人均家庭卫生支出在经济发达的邦较高，与支付能力相关，但在印度较贫穷和较发达的邦，灾难性卫生支出（CHS）同样较高。基于多层次建模，我们发现卫生支出和 CHS 的最大地域差异存在于邦和村庄层面，反映出这些层面的医疗保健获取和成本存在广泛的不平等。宏观和微观政治单位的背景因素对于降低印度的卫生支出和 CHS 很重要。
在印度，医疗保健是一种地方公共产品，家庭是其主要资金来源。先前的研究考察了卫生保健支出的多种决定因素，但尚未有人试图了解家庭和灾难性卫生支出的地域差异。我们使用多层次建模来评估村庄、地区和邦对印度家庭卫生支出的相对重要性。
我们使用了 2011-2012 年国家抽样调查消费支出附表（第 68 轮）中收集的 101576 户家庭的卫生支出数据。我们考察了 4 个因变量：人均卫生支出（PHS）、人均机构卫生支出（PIHS）、人均非机构卫生支出（PNHS）和灾难性卫生支出（CHS）。CHS 定义为家庭卫生支出超过其支付能力的 40%。我们使用多层次线性回归和逻辑模型来分解每个结果在邦、地区、区、村庄和家庭层面的差异。
平均 PHS 为 1331 印度卢比（INR），因邦的经济发展水平而异。约四分之一的印度家庭发生了 CHS，在经济发达和较贫穷的邦中，CHS 的发生率同样较高。在控制了家庭层面的因素后，PHS 的总变异中有 77.1%归因于家庭，10.1%归因于邦，9.5%归因于村庄，2.6%归因于区，0.7%归因于地区。PNHS 的方差分配模式相似。CHS 的州际差异最大（15.9%），而 PIHS 则相反（3.2%）。
与印度的区和地区相比，我们观察到家庭卫生支出在邦和村庄层面存在较大差异。CHS 的州际差异较大表明医疗保健获取和成本方面的州际不平等。我们的研究结果表明，宏观和微观政治单位的背景因素对于降低印度的家庭卫生支出和 CHS 很重要。
